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Transitions Clinic Network: Transforming the Healthcare System in
Partnership with Justice-Involved Individuals
Shira Shavit, MD Executive Director, Transitions Clinic Network
Associate Clinical Professor Dept. Family and Community Medicine University of California, San Francisco
• The project described was supported by Grant Number 1CMS331071-01-00 and 1C1CMS331300-01-00 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services.
• Disclaimer: The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. The research presented here was conducted by the awardee. Findings might or might not be consistent with or confirmed by the findings of the independent evaluation contractor.
Outline
• Background: Why is caring for patients with a history of
incarceration any different than other patients?
• Transitions Clinic model: Creating a model of primary care specific to patients with a history of incarceration
• Transitions Clinic Network: Scaling up the model
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Patient demographic is changing.
Healthcare is constitutionally guaranteed in prison.
Prison environments can exacerbate poor health.
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Image Courtesy of Ray Chavez and CA Prison Health Care Receivership Access is limited by institutional policies.
Image Courtesy of Ray Chavez and CA Prison Health Care Receivership Self management of chronic conditions is difficult.
Image Courtesy of Ray Chavez and CA Prison Health Care Receivership
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Almost everyone goes home.
Health-related Reentry Challenges
• No discharge planning and short supply of medications1
• No health insurance/lapse in Medicaid and
Medicare B2
• Individuals convicted of drug felonies face
additional barriers to meeting basic needs: food stamps, WIC, section 8 housing3
1 N.A. Flanagan, et al. Can J Nurs Res 2004, 2 N. Birnbaum, et al., E.A. Wang, AJPH 2014, 3E.A. Wang, et al. AIDS Educ Prev 2013.
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Health Risks Following Release
Chronic medical conditions, HIV and substance dependence1
Increased odds of developing hypertension2
Hospitalization3,4
Death5,6
Incarceration
1 EA Wang, et al. JAD 2014, MJ Milloy, et.al. JID 2011. 2 EA Wang, Archives of Internal Med 2009 3 EA Wang, et. al. JAMA Internal Medicine, July 2013. 4 JW Frank, et al. EA Wang, JGIM 2014 , 5IA Binwanger, NEJM 2007; 6D Rosen, AJPH 2008.
Community
Binswanger, et al NEJM 2007; 356:157-65
12 times increased risk of death in first 2 weeks after release
The leading causes of death: 1. Drug overdose 2. Cardiovascular disease 3. Homicide 4. Suicide 5. Cancer
Release from Prison—A High Risk of Death for Former Prisoners
Barriers to Care Engagement
Correctional System
Community & Healthcare system Individual
Barriers
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Discrimination • Already experienced discrimination in the healthcare setting based
on socioeconomic status, racial and ethnic backgrounds, and lower levels of education1-4
• Resulting in psychological distress and reduced healthcare engagment5
• Less likely to have routine physical within the past year, delays in care, poor adherence to recommended care, and decreased use of preventive services6-10
• 42% of recently prisoners experienced discrimination based on CJ history11
1.Williams DR, Neighbors HW, Jackson JS. Racial/ethnic discrimination and health: findings from community studies. Am J Public Health 2003;93(2):200-8. 2.Paradies Y. A systematic review of empirical research on self-reported racism and health. Int J Epidemiol 2006;35(4):888-901. 3.Shavers VL, Fagan P, Jones D, Klein WM, Boyington J, Moten C, et al. The state of research on racial/ethnic discrimination in the receipt of health care. Am J Public 3.Health 2012;102(5):953-66. 4.Grollman EA. Multiple forms of perceived discrimination and health among adolescents and young adults. J Health Soc Behav 2012;53(2):199-214 5. Turney K, Lee H, Comfort M. Discrimination and Psychological Distress Among Recently Released Male Prisoners. Am J Mens Health 2013. 6. Van Houtven CH, Voils CI, Oddone EZ, Weinfurt KP, Friedman JY, Schulman KA, et al. Perceived discrimination and reported delay of pharmacy prescriptions and medical tests. J Gen Intern Med 2005;20(7):578-83. 7. Casagrande SS, Gary TL, LaVeist TA, Gaskin DJ, Cooper LA. Perceived discrimination and adherence to medical care in a racially integrated community. J Gen Intern Med 2007;22(3):389- 8. Hausmann LR, Jeong K, Bost JE, Ibrahim SA. Perceived discrimination in health care and use of preventive health services. J Gen Intern Med 2008;23(10):1679-84. 9. Benjamins MR. Race/Ethnic Discrimination and Preventive Service Utilization in a Sample of Whites, Blacks, Mexicans, and Puerto Ricans. Med Care 2012. 10. Blanchard J, Lurie N. R-E-S-P-E-C-T: patient reports of disrespect in the health care setting and its impact on care. J Fam Pract 2004;53(9):721-30. 11. Frank, J, Discrimination based on criminal record and healthcare utilization among men recently released from prison: a descriptive study. Health Justice. 2014 Mar 25;2:6
Transitions Clinic Program, Southeast HC, SFHN
Using Community Engagement to convene
Transitions Clinic Community Advisory Board
Bayview Neighborhood Residents Transitions Clinic patients
All of Us or None Legal Services for Prisoners with Children
San Francisco Reentry Council City of San Francisco
San Francisco Department of Public Health Southeast Health Center
University of California, San Francisco
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Strategies to Successful Engagement Post-Release
• Include individuals and communities impacted by criminal justice
system in design, implementation and evaluation of programs
• Broad Definition of health & well-being
• Adapt systems to be patient-centered
• Empower patients
• Favor reintegration
• Avoid replication of correctional system
Patient Centered Care for Returning Prisoners Culturally competent primary care teams
Certified community health worker (CHW) with past history of incarceration to assist with patient navigation, care management, and chronic disease self-management support)
Patient centered services; i.e. access to primary care within 2 weeks of release (starting in prison), behavioral health integration, re-entry support
Partnerships with existing community organizations that serve formerly incarcerated individuals
Role of the Community Health Worker
Outreach
Meeting our patients where
they are at (literally)
Parole
Home
Jail/prison
Hospital
Treatment
facilities
The streets
Health System Navigation
Guide for the complex medical
system.
Medication assistance
Health insurance
Specialty appointments
Pharmacy, lab, radiology
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Role of the Community Health Worker
Referrals & Advocacy: Housing ,employment, job
training , education and other social services.
Health Education: Educating patients about their
chronic diseases especially new diagnoses.
Chronic Disease Self
Management: Education about self-reliance and
chronic disease management.
Emotional Support & Mentorship
TC study: Methods
• Community-based participatory research1 – “collaborative approach to research that equitably involves all
partners in the research process and recognizes the unique strengths that each brings.”
• Designed a Randomized Controlled Trial
• Transitions clinic program vs. expedited primary care
• Outcomes: 12 month administrative data from
electronic health record and county jail
1. Israel BA, Eng E, Schulz AJ, eds. Methods in Community-Based Participatory Research for Health. San Francisco, Calif: Jossey-Bass; 2003.
TC study: Results
Outcome
Randomized to Transitions Clinic (N=98)
Randomized to Expedited Primary Care (N=102) p-value
Primary care utilization
Two or more visits to assigned clinic 37 (37.7) 48 (47.1) 0.18
Any Emergency Department Use 25 (25.5) 40 (39.2) 0.04
Any Hospitalization 10 (10.2) 15 (14.7) 0.34
Any Incarceration (Jail) 57 (58.1) 54 (52.9) 0.46
E.A. Wang, et. al. AJPH 2012 Jul 19.
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One Year ED Utilization
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0 visits 1 visit 2-3 visits >4 visits
TransitionsClinicExpeditedPrimary Care
# of visits
Pro
port
ion o
f
part
icip
ants
Wilcoxon test p< 0.001 E.A. Wang, et. al., AJPH 2012
Est. Cost
Savings:
• avg. $912
per patient,
per year
• avg.
$91,000 per
100
patients, per
year
“Engaging High-Risk Medicaid Patients leaving Prison into Primary Care: Transitions Clinic Network”
• CMS Health Care Innovations Award Recipient 2012-2015
• Provide primary care to 2000+
patients leaving prison
• 13 programs in 6 states and Puerto Rico
• San Jose, CA
• Richmond, CA
• San Francisco, CA
• Pittsburgh, CA
• Caguas, Puerto Rico
• New York, NY
• Rochester, NY
• Boston, MA
• New Haven, CT
• Birmingham, AL
• Baltimore, MD
• Bronx, NY
Hiring and training a new CHW workforce
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Training Community Health Workers
Post Prison Community Health Worker Curriculum, City College of San Francisco; 20 units
Train previously incarcerated CHW students to care for recently released prisoners
Online training
On-site internships (128 hours) for CHW students mentored by seasoned CHWs
TCN Technical Assistance: Professional Development
Cultural competency training 12 part training
Clinical skill building for CHWS/clinicians
Team Based Care
On-site rotations for residents and medical students
TCN Technical Assistance: Program Implementation
Program Implementation
• Hiring, supervision and integration of CHW
• Re-entry & Criminal Justice Partnerships
• Patient-Centered Services
• Patient recruitment & retention
• Sustainability
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Hiring Formerly Incarcerated Individuals to Work in Clinical Settings
• Equal Employment Opportunity Commission states that employers cannot deny individuals a job based on criminal record
• Still barriers to hiring formerly incarcerated individuals, including a criminal record box on applications
-At least 14 states, 51 cities have banned the box
• “Thinking Outside the Box: Hospitals Promoting Employment for Formerly Incarcerated Persons” Annals of Internal Medicine by Aaron Fox
TCN Technical Assistance: Evaluation
Evaluation/Research
• Assisting with IRB/OHRP approval
• Obtaining consent, survey administration and data entry
• Clinical constant quality improvement
• Community based participatory research
Transitions Clinic Network
Puerto Rico
TCN Interest (25)
TCN Site (16)
TCN California San Francisco Contra Costa
Alameda Santa Clara
Solano Los Angeles
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Acknowledgements Transitions Clinic Network
Jenerius Aminawung, MD, MPH
Tim Berthold, MPH
Nathan Birnbaum
Susan Busch, PhD
Joe Calderon, CHW
Amie Fishman, MPH
Scott Greenberg
Jerry Smart, CHW
Lisa Pham
Lisa Puglisi, MD
Ron Sanders, CHW
Anna Steiner, MSW, MPH
Shira Shavit, MD
TCN Liaisons, TCN CHWs, and panel managers
TCN patients
TCN Community Partners
National Advisory Board
Network Funding
Langeloth Foundation
CMMI Healthcare Innovation Award
1C1CMS331071-03-00
Patient Centered Outcomes Research Institute
Department of Justice
The California Endowment
The San Francisco Foundation
The California Healthcare Foundation
The Tow Foundation
The Solomon Family Foundation
The Robert Wood Johnson Foundation
The California Wellness Foundation
Program Support
SF DPH/ Southeast Health Center
Alameda Department Health Care Services Agency/Roots
Contra Costa Health Services/Health Conductors
Santa Clara County Office of Reentry Services/Valley Medical Center
Partnership HealthPlan/La Clinica de La Raza
Blue Shield Foundation/LA Care/LAC DHS
D
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Thank you!
Questions?
Contact information:
Shira Shavit, MD
Executive Director
415-476-2148
Anna Steiner, MSW, MPH
Program Director
415-502-2441
• The project described was supported by Grant Number 1CMS331071-01-00 and 1C1CMS331300-01-00 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services.
• Disclaimer: The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. The research presented here was conducted by the awardee. Findings might or might not be consistent with or confirmed by the findings of the independent evaluation contractor.